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The new drug benefit at a glance

Published November 8, 2005 12:01 am
This is an archived article that was published on sltrib.com in 2005, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.

Enrollment begins Nov. 15. Medicare will have an online enrollment center; or you can call the toll-free number of the plan you have chosen; or mail an application to the plan; or visit the plan's website.

Coverage begins Jan. 1, for those who have signed up for a plan by Dec. 31.

Deadline May 15, for seniors without existing, comparable drug coverage and who want to avoid a late-enrollment penalty.

Joining late After the May 15 deadline, beneficiaries face a penalty and can join only from Nov. 15 to Dec. 31 of each year.

Joining when you're eligible If you turn 65 or otherwise become eligible for Medicare, you have seven months to enroll and avoid a penalty. If you lose your existing, comparable coverage, you have 63 days to enroll.

Explaining the penalty

Seniors with prescription coverage through an insurance plan do not have to opt into a Medicare-approved plan. If they do so later, they will not be penalized.

But seniors who do not have drug coverage and do not join a plan now will be penalized if they join after May 15, 2006.

The penalty is 1 percent of the national average premium for each month without drug insurance. There is no cap on the number of months the penalty may be assessed, and the average premium may increase.

Here is an example of how that will work.

Currently, the average premium nationwide is $32.50 per month. The 1 percent penalty amounts to 33 cents per month. If you were to join in December 2006 - considered seven months late - you would pay $2.31 per month on top of the monthly premium charged by the plan you select.

-- Brooke Adams

Appealing: If you and your plan disagree

What if you have a dispute with the plan you choose?

One example: plans may change the drugs they cover, possibly dropping one your doctor says you need.

First, plans must give you 60 days' notice. You can ask to keep your access to the drug at the same price.

The plan must repond within 72 hours, or within 24 hours for an expedited request. If your request is denied, there are five levels of appeal.

1. Ask the plan to reconsider. It must respond within 7 days, or 72 hours for an expedited request.

2. Then, seek an independent review by Maximus Federal Services, hired by the Centers for Medicare and Medicaid Services. It will do a "paper review" of your appeal, Medicare says, and faces the same deadlines as above.

3. Next, ask an administrative law judge with the federal Department of Health and Human Services to review your case, if the drug cost meets a minimum standard, currently $100. Utah appeals are handled by a western field office in Irvine, Calif.

4. Appeal to the Medicare Appeals Council in Washington, D.C., where one or more administrative appeals judges will consider your case.

5. If rejected and the drug cost is at least $1,050, Utahns can file a civil lawsuit in U.S. District Court in Salt Lake City.

"If this is truly medically necessary, somebody in this process is going to say yes," said Warren Young, assistant pharmacy director for Smith's Food and Drug Stores. "There is definitely a federal safety net."

Low-income Utahns can receive help with appeals from Utah Legal Services at (801) 328-8891.

-- Sheila R. McCann




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